By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (Pomalidomide) Covered by Humana in Texas: Complete PA Guide and Appeals Process

Answer Box: Getting Pomalyst Covered by Humana in Texas

Pomalyst (pomalidomide) requires prior authorization from Humana with step therapy through lenalidomide first. You'll need REMS program enrollment, proof of prior lenalidomide + proteasome inhibitor failure, and oncologist documentation. Start today: 1) Enroll in PS-Pomalidomide REMS at bmsremspatientsafety.com, 2) Gather prior therapy records showing lenalidomide progression, 3) Have your oncologist submit PA with medical necessity letter. Appeals available within 65 days if denied, with expedited 72-hour review for urgent cases.

Table of Contents

  1. Humana Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization & Step Therapy Requirements
  4. REMS Program Requirements
  5. Specialty Pharmacy Network
  6. Cost-Share Basics
  7. Step-by-Step: Fastest Path to Approval
  8. Common Denial Reasons & How to Fix Them
  9. Appeals Process in Texas
  10. Clinician Corner: Medical Necessity Letter
  11. Costs & Patient Assistance
  12. FAQ

Humana Plan Types & Coverage Implications

Humana's coverage for Pomalyst varies significantly by plan type in Texas:

Medicare Advantage (MA) Plans: Most common Humana coverage in Texas. Pomalyst requires prior authorization with step therapy through lenalidomide as the preferred alternative. New enrollees get 90-day transition coverage for existing therapies.

Medicare Part D Plans: Follow similar PA requirements but may have different formulary tiers. Contact Humana pharmacy services to verify your specific plan's coverage.

Dual Eligible Special Needs Plans (D-SNP): Include both Medicare and Medicaid benefits with the same PA requirements as standard MA plans.

Note: ERISA self-funded employer plans and Medicare Supplement plans follow different rules than what's outlined here.

Formulary Status & Tier Placement

Pomalyst requires prior authorization on Humana formularies, though specific tier placement varies by plan. Most specialty oncology drugs like Pomalyst fall on specialty tiers with higher cost-sharing.

To check your plan's specifics:

  • Log into MyHumana account
  • Use the drug search tool for your plan's exact tier and PA criteria
  • Download your Prescription Drug Guide (PDG)

The drug is typically classified as non-preferred compared to lenalidomide (Revlimid), which explains the step therapy requirement.

Prior Authorization & Step Therapy Requirements

Coverage Requirements Table

Requirement What It Means Documentation Needed
Step Therapy Must fail lenalidomide first Prior therapy timeline, progression dates
Prior Proteasome Inhibitor Must have tried bortezomib, carfilzomib, or ixazomib Treatment records, failure/intolerance notes
≥2 Prior Therapies At least two previous myeloma treatments Complete treatment history
Progression ≤60 Days Disease progressed within 60 days of last therapy Recent scans, lab values, oncologist notes
REMS Enrollment PS-Pomalidomide safety program REMS confirmation number

Submission Process

Submit PA requests through:

  • Provider portal: provider.humana.com
  • Phone: 800-555-CLIN (2546), Mon-Fri 8am-6pm ET
  • Clinical documentation: Include patient demographics, HCPCS codes, primary diagnosis (ICD-10: C90.x for multiple myeloma), and detailed clinical justification

Timeline: Standard decisions within 30 days for pre-service requests; expedited reviews available for urgent cases.

REMS Program Requirements

Pomalyst is only available through the FDA-mandated PS-Pomalidomide REMS program due to severe birth defect risks.

Required Steps:

  1. Prescriber Certification: Oncologist must enroll and certify through REMS portal
  2. Patient Enrollment: Complete Patient-Physician Agreement form
  3. Contraception Requirements: Two reliable birth control methods for all patients (male and female)
  4. Monthly Surveys: Ongoing compliance monitoring
  5. Pharmacy Certification: Only REMS-certified pharmacies can dispense

Dispensing Rules:

  • Maximum 28-day supply per prescription
  • No automatic refills or phone prescriptions
  • 24-hour confirmation number validity
  • Same-day shipping for females of reproductive potential
Tip: REMS enrollment typically takes 1-2 days and must be completed before Humana PA submission.

Specialty Pharmacy Network

Humana partners with CenterWell Specialty Pharmacy for specialty drug distribution. However, verify current preferred partners as network arrangements can change.

For Pomalyst specifically:

  • Must use REMS-certified pharmacy from BMS network list
  • Coordinate with your oncologist's office for specialty pharmacy setup
  • Contact Humana member services (number on your ID card) for Texas-specific preferred partners

Cost-Share Basics

Specialty tier drugs typically involve:

  • Deductible: May need to be met before coverage begins
  • Coinsurance: Usually 25-40% for specialty tiers
  • Out-of-pocket maximum: Protects against catastrophic costs

Important: These are educational examples only. Your specific costs depend on your plan details, which you can find in your Evidence of Coverage document.

Step-by-Step: Fastest Path to Approval

1. REMS Enrollment (1-2 days)

Who: Patient and prescriber
Action: Register at bmsremspatientsafety.com
Documents: Patient-Physician Agreement, contraception attestation

2. Gather Clinical Documentation (Same day)

Who: Oncologist's office
Action: Compile treatment history and progression evidence
Documents: Prior therapy timeline, recent imaging, lab values

3. Submit Prior Authorization (Same day)

Who: Prescriber
Action: Submit PA through Humana provider portal
Documents: REMS confirmation, medical necessity letter, clinical notes

4. Follow Up (3-7 days)

Who: Patient or clinic staff
Action: Contact Humana if no decision received
Timeline: 30 days standard, 72 hours expedited

5. Appeal if Denied (Within 65 days)

Who: Patient, prescriber, or representative
Action: File redetermination request
Method: Humana appeals process or call 800-867-6601

Common Denial Reasons & How to Fix Them

Denial Reason Solution Required Documentation
Step therapy not met Document lenalidomide failure/intolerance Prior therapy records with progression dates
Missing proteasome inhibitor Provide PI treatment history Bortezomib/carfilzomib/ixazomib records
REMS not enrolled Complete REMS registration REMS confirmation number
Insufficient progression evidence Submit recent imaging/labs Scans within 60 days, progression notes
Non-specialist prescriber Transfer to oncologist/hematologist Specialist consultation notes
From our advocates: We've seen cases where initial denials were overturned simply by resubmitting with complete REMS documentation and a detailed timeline showing lenalidomide progression within the required 60-day window. The key is thorough documentation upfront.

Appeals Process in Texas

Medicare Part D Appeals Timeline

Level 1 - Redetermination:

  • Deadline: 65 days from denial notice
  • Decision time: 7 days standard, 72 hours expedited
  • Submit to: Humana appeals or 800-867-6601

Level 2 - Independent Review:

  • Automatic: If Level 1 denied or timeline missed
  • Decision time: 7 days standard, 72 hours expedited

Expedited Review Criteria: Available when prescriber states delay would seriously jeopardize life, health, or function—common for oncology drugs like Pomalyst.

Texas State Resources

For additional support:

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Independent Review Organization info: 1-866-554-4926
Note: Medicare plans follow federal appeal rules, not Texas state IRO process.

Clinician Corner: Medical Necessity Letter

Essential Elements for Pomalyst PA:

Patient Information:

  • Diagnosis: Multiple myeloma with ICD-10 code (C90.x)
  • Performance status and current condition
  • Treatment goals and prognosis

Prior Therapy Documentation:

  • Lenalidomide: doses, duration, response, progression date
  • Proteasome inhibitor: specific agent, response, toxicity/failure reason
  • Other prior therapies and outcomes

Clinical Rationale:

Dosing Plan:

  • Proposed Pomalyst dose (typically 4 mg daily, days 1-21/28)
  • Combination with dexamethasone
  • Monitoring plan

Supporting Guidelines: Reference NCCN Multiple Myeloma Guidelines or ASH/ASCO recommendations where applicable.

Costs & Patient Assistance

Pomalyst retail costs approximately $23,400 for a 21-capsule pack (one cycle). Several assistance options exist:

Bristol Myers Squibb Access Support:

  • Coverage verification and PA assistance
  • Copay support for eligible patients
  • Free drug programs for qualifying uninsured patients
  • Contact: BMS Access Support

Medicare Coverage: Pomalyst is included in HHS's 2025 Medicare drug price negotiation list, with new prices expected to affect Part D coverage in 2027.

Foundation Grants: Various patient assistance foundations offer grants for specialty oncology drugs. Eligibility typically based on income and insurance status.

FAQ

Q: How long does Humana prior authorization take for Pomalyst in Texas?
A: Standard PA decisions within 30 days; expedited reviews within 72 hours if medical urgency is documented. Source

Q: What if Pomalyst is non-formulary on my Humana plan?
A: Request a formulary exception through the same PA process, emphasizing medical necessity and failure of formulary alternatives.

Q: Can I get an expedited appeal for Pomalyst denial?
A: Yes, if your prescriber states that delay would jeopardize your health. Call 800-867-6601 for expedited redetermination.

Q: Does step therapy apply if I failed lenalidomide outside Texas?
A: Yes, step therapy requirements are based on medical history, not geography. Provide documentation of prior lenalidomide failure regardless of where treatment occurred.

Q: What happens if I miss the 65-day appeal deadline?
A: Contact Humana to request an extension for "good cause" or file a new PA request with updated clinical information.

Q: Is REMS enrollment required even with PA approval?
A: Yes, REMS enrollment is FDA-mandated and required regardless of insurance approval. No pharmacy can dispense Pomalyst without REMS compliance.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payers' own rules, pulling the right clinical evidence and operational details that payers expect for drugs like Pomalyst.

For complex cases involving multiple prior therapies or unusual clinical circumstances, consider working with experienced appeal advocates who understand both Humana's specific requirements and the nuances of multiple myeloma treatment protocols. The platform at Counterforce Health specializes in these evidence-based approaches that can significantly improve approval rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or insurance advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For questions about Texas insurance regulations, contact the Texas Department of Insurance at 1-800-252-3439.

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